Acne Survey Age 12-up

In order to determine if you pre-qualify for this acne research study, we will ask you a few questions about your acne and what you may have tried to deal with it. You may stop answering at any time and do not need to answer any questions that make you feel uncomfortable. All information you provide will be kept confidential. Please feel free to call us for more information at (619) 512-DERM.

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1.
Please tell us about yourself.

Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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2.
Are you age 12 or older?

Yes

No

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3.
Participants from 12 to 17 years of age must have a parent or legal guardian complete this short survey. Are you the parent or legal guardian of someone interested in this study?